About a million women in the USA have a tubal ligation every year and about 1% of these patients seek reversal at some point. Younger women tend to regret their ligation more often (up to 20% of those who had a ligation in their 20s), as well as those who are in new relationships.
Although a tubal ligation is a form of female permanent sterilization, there are two excellent options for patients who would like to conceive after a ligation: Tubal reversal (also known as tubal reanastomosis) or in vitro fertilization (IVF).
IVF is the most well known of the two options as it is more widely accessible due to its use for multiple other indications beyond tubal factor, such as male infertility, pelvic adhesions, unexplained infertility, pregenetic diagnosis and many others. IVF does not require surgery and is very efficient (pregnancy is usually attained faster), but it can be more expensive and requires more visits to the clinic. IVF also carries a higher risk of multiple gestations (twins) as well as ovarian hyperstimulation syndrome.
A tubal reversal is a surgical procedure that restores patency of the fallopian tubes and thus allows the couple to conceive naturally. Therefore, ideal candidates are those who have no other fertility issues:
- Normal monthly ovulation and periods
- Normal semen analysis
- Low risk of pelvic adhesions from prior surgeries (C sections, appendectomy, pelvic surgery)
- About 6 cm of healthy tube remaining
The amount of healthy tube remaining depends on the type of tubal ligation performed. Clips and rings produce the most predictable and least amount of damage, while cautery (burning) and cutting of the tube result in a wide range of tubal injury. The operative report of the tubal sterilization procedure gives us the best estimate of the length of tube that was damaged. Other tools that can be used to assess tubal length are laparoscopy and hyterosalpingography (HSG).
The advantages of tubal reversal are:
- Similar pregnancy rates to IVF in the long-term, up to 80%
- Natural conception, more privacy, few doctor visits
- Lower cost
- Multiple pregnancies possible without additional cost
- No need to use injectable hormones and thus minimal risk of twins and hyperstimulation
- Ovarian reserve is less crucial
The disadvantages are:
- Other fertility issues will significantly lower pregnancy rates
- Longer time to conceive
- Higher risk of ectopic pregnancy
- Future need of contraception (as tubes are patent)
- Essure is not reversible
The procedure is done via conventional laparotomy, mini-laparotomy, laparoscopy or the robot.
Laparoscopy appears to have slightly lower success rates and the robotic approach may double or triple the cost of the procedure. The laparotomy approach requires hospitalization, is more expensive, the incision is larger, less cosmetically appealing and requires longer healing time. I prefer the mini-laparotomy approach. The incision is about 1.5-2 inches above the pubic hairline (bikini area) and it allows the patient to go home the same day. The surgery is done by 2 physicians using microscopes or surgical loops, it takes about 1-2 hours, and the patient needs about 2 weeks to recover at home.
In summary, IVF and tubal reversal are excellent options for patients who have had a tubal ligation. IVF may be a better choice for those with multiple fertility issues, post Essure or people who desire to shorten the time to conception. Tubal reversal is a more affordable and natural approach, with a minimal need for doctor visits and medication use. At ReproMed we specialize in both alternatives and after a short evaluation we are generally able to help you decide which approach is best for you.